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Health Affairs' December Issue for Health Reform Optimists, Pessimists and Everyone in Between

Variety issue covers public health successes and system weaknesses


Bethesda, MD -- Health Affairs focuses on a variety of topics in its December issue, including why many consumers in high-deductible health plans don't use preventive care benefits; why many hospices won't enroll high-cost patients; how Medicare Advantage health maintenance organizations (HMOs) may experience more appropriate use of services than traditional Medicare; and how efforts to ban smoking or entice smokers to quit have succeeded and improved health.

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Patients in high deductible consumer-directed health plans avoid preventive care due to unnecessary fears over cost. Consumer-directed plans typically exempt recommended preventive visits and tests from the plan's deductible, or require only a small copay. These plans have grown in popularity, increasing to 19 percent of all covered workers in 2012 from 8 percent just three years prior. Mary E. Reed, of the Kaiser Permanente Northern California Division of Research, and coauthors found that more than half of the 456 Northern California-based respondents surveyed did not understand their plan benefits for preventive office visits and approximately one in five delayed or avoided a preventive visit, test, or screening because of cost.

The authors recommend concerted consumer education and support efforts to ensure patients are aware of their benefits and do not mistakenly avoid important preventive care due to concerns over cost, especially as more private and public health plans adopt the consumer-directed plan model.

Hospices' own enrollment policies may contribute to underuse of hospice in the United States.
Melissa D. Aldridge Carlson, of the Mount Sinai School of Medicine, and coauthors conducted the first national survey of enrollment policies at US hospices and concluded that 78 percent of the 591 in the sample had at least one enrollment policy that could restrict access for terminally ill Medicare patients with high-cost medical needs such as chemotherapy, transfusions, or palliative radiation.

The number of hospices has increased by 53 percent from 2000 to 2010, caring for 1.1 million Medicare beneficiaries whose combined per diem reimbursements make up 84 percent of overall annual hospice revenue. Yet because Medicare payment to hospices does not adjust for cost or intensity of care required, hospices may have difficulty accepting patients with potentially high-cost needs, especially smaller hospices. The authors suggest changing Medicare's reimbursement rates and clarifying eligibility requirements might help improve access and ensure a more equitable distribution of care across geographic regions.

Medicare Advantage HMO enrollees use fewer services and might be experiencing more appropriate utilization of services than traditional Medicare patients. Bruce Landon, of Harvard Medical School, and coauthors examined the service utilization patterns of Medicare Advantage HMO and traditional Medicare enrollees in important categories that can demonstrate the impact of integrated care. The authors found 25-35 percent lower emergency department use and 20-25 percent lower inpatient medical days among the HMO patients. Inpatient surgical days were initially lower as well but equalized over time between the two groups.

Elective knee and hip replacement use was 10-20 percent lower depending on the specific timeframe for entry into the Medicare Advantage program by HMO plans, and HMO patients used coronary artery bypass graft surgery at consistently higher rates in accordance with current practice guidelines. These findings are consistent with claims by proponents of managed care that an integrated approach used by Medicare Advantage HMO plans and others appears to be successfully controlling health care utilization and promoting appropriate use of recommended services and can inform emerging models such as accountable care organizations.

Benefits of smoking bans go well beyond reducing hospitalizations for heart attacks in smokers--and get even better over time. Mark V. Vander Weg, of the Iowa City VA Health Care System and the University of Iowa's Carver College of Medicine Department of Psychology, and colleagues analyzed the relationship between smoking bans passed across the United States between 1991 and 2008 in workplaces, restaurants, and bars and hospital admissions for certain smoking-related illnesses among Medicare beneficiaries age sixty-five and older.

They found that admission rates for acute myocardial infarction fell 20-21 percent thirty-six months after a ban was in place. Admissions for chronic obstructive pulmonary disease fell 11 percent after workplace bans and 15 percent after bar smoking bans were enacted. Counties with bans in two or three locations saw an even greater compounded benefit.

For points of comparison, the authors also assessed two conditions not expected to be strongly affected by smoking bans and found minimal or modest change in admission rates for gastrointestinal hemorrhage and hip fracture over the period of study. The authors conclude that the positive effects of smoke-free laws over time--particularly bans in multiple locations simultaneously--are significant and support the health benefits of limiting exposure to tobacco smoke.

Another related article of interest is by Wenya Yang, of the Lewin Group, and coauthors: Simulation of Quitting Smoking in the Military Shows Higher Lifetime Medical Spending More Than Offset by Productivity Gains.

About Health Affairs

Health Affairs is the leading journal at the intersection of health, health care, and policy. Published by Project HOPE, the peer-reviewed journal appears each month in print, with additional Web First papers published periodically at The full text of each Health Affairs Web First paper is available free of charge to all website visitors for a two-week period following posting, after which it switches to pay-per-view for nonsubscribers. Web First papers are supported in part by a grant from The Commonwealth Fund. You can also find the journal on Facebook and Twitter. Read daily perspectives on Health Affairs Blog. Download our podcasts, including monthly Narrative Matters essays, on iTunes. Tap into Health Affairs content with the new iPad app.